Let’s talk about sex. And vaccines. More specifically, a vaccine that is intimately associated with sex–the HPV vaccine. Maybe your child is approaching the age when you have to make a decision about this vaccine. Maybe your kids are so young, you’re not even thinking about it yet. Or perhaps your child already got the vaccine, but you have some doubts about whether you made the right decision. Whatever stage of parenting you’re in right now, it’s an important topic–and one that tends to cause quite a bit of controversy.
Human papilloma virus, or HPV, is a virus that causes warts…and cancer. There are hundreds of strains of this virus, and each strain tends to cause its own set of problems:
- Strains 2, 7, and 22 typically cause common warts–like the kind you might have on your hands.
- Strains 1, 2, 4, and 63 cause plantar warts, which are painful warts on the soles of the feet.
- Strains 6, 11, 42, and 44 cause genital warts, which are unsightly and embarrassing, and can cause quite a bit of emotional distress. (Additionally, babies born to mothers with genital warts can develop a rare disease called juvenile-onset recurrent respiratory papillomatosis–a condition in which the virus causes growths within the child’s airway that can require surgical intervention.)
- And, unfortunately, many strains cause cancer: 16, 18, 31, and 45 are the highest risk, but 33, 35, 39, 51, 52, 56, 58, 59 have been implicated as well. The cervix is the most common location, but these cancers can also affect the penis, the vagina or vulva, the anus, or the mouth and throat.
HPV is the most common sexually-transmitted infection. There are about 14 million new infections in the US every year, and about 50% of adults in the US have been exposed at some point. While the majority of these infections resolve on their own and go completely unnoticed, some of them will be far more problematic. Unlike many other sexually-transmitted infections, transmission of HPV isn’t prevented with barrier methods like condoms, because the virus often lives in areas that aren’t covered. And spreading the virus doesn’t even require “sex,” per se. HPV is like the bocce of STDs–sometimes “pretty close” is close enough.
In case you’ve ever wondered about the reason for Pap smears, it’s HPV. The strains that cause cervical cancer tend to follow a predictable pattern–they cause mutations in cells that can be detected with a microscope. Over time, these abnormal cells may be eradicated by the immune system, or they may continue to become more and more abnormal, eventually progressing to cancer. (I’ll leave the rest of the details to my OB/GYN colleagues.) The purpose of Pap smears is to catch these lesions early, remove them with the least invasive surgery possible, and keep them from developing into high-grade cancers. While Pap smear screening has helped quite a bit, the most recent estimates are that 12,500 women will be diagnosed with invasive cervical cancer this year, 4,100 of whom will die from the disease. And while most of these women are diagnosed in their 30’s or 40’s, their exposure to the virus happened years (sometimes decades) before.
But what if–instead of finding cancers early and surgically removing them–we could prevent them entirely? Why settle for a cure for cancer, if we can eradicate it? Fortunately, we can prevent the vast majority of HPV-related cancers with a simple vaccine. (Although, to be fair, the HPV vaccine isn’t the only vaccine that prevents cancer; the hepatitis B vaccine does that, too.)
When is the HPV vaccine given?
The current recommendation is to give the HPV vaccine to all children (boys and girls) between the ages of 11 and 12, but it can be given to children as young as 9. The vaccine is given in a 3-dose series over a 6-month period. For those that didn’t get it at 11-12, the vaccine can be given–in many circumstances–up to age 26. There are a few reasons for this timing. One is that children in early adolescence have a better immune response to the vaccine than older teenagers. Another is that as children get older, they don’t tend to visit the doctor as frequently, and would be less likely to get the vaccine. And the big one–that none of us wants to think about–is that kids have sex. Because vaccines work by preventing diseases and not by treating them, they have to be given before exposure. The 11-12 year-old range allows us to reach the vast majority of children before their first sexual encounter, and the risk prior to this age is minimal.
My child isn’t sexually active. Does he/she still need the HPV vaccine?
Well…yes. Here are a few points to consider:
- While I hope you’re right about your child’s abstinence, I’ve seen enough kids and read enough statistics to know that some of you are wrong. Half of high school students have had sex. Some kids start way earlier.
- While I truly hope that your children will make wise decisions and uphold the moral values that you’ve worked to instill into them, that doesn’t always happen. Trust me, this isn’t a topic that I like to consider with regard to my own children. But it’s reality.
- Because the goal is to prevent infection, the vaccine needs to be given before the onset of sexual activity–not when you have reason to believe something’s going on.
- It doesn’t take “sex” to spread HPV, and kids are more creative than you’d like to think.
- You have control over a vaccine at age 11. You have far less control over your child’s decisions in college and beyond.
- Even if your child remains abstinent until marriage, there’s a possibility that he/she will marry someone who didn’t. (Or someone who at least got close enough.)
Does protecting my child against a sexually-transmitted infection encourage sexual activity?
This is a very common question, and it’s a big reason that parents hesitate to immunize children against HPV. But the answer is no–just as air bags don’t encourage reckless driving, protecting children from this disease does not encourage promiscuity. There’s actually a lot of science out there to support this. Despite our reasonable fears, it simply isn’t true.
There are three HPV vaccines–which one should I choose?
In 2006, the first HPV vaccine, Gardasil, was approved for use in the US. It provides protection against 4 strains of HPV (6, 11, 16, and 18)–the two strains most frequently responsible for cancer, and two strains that cause genital warts. Another manufacturer developed a vaccine called Cervarix, which was approved in 2009 and provides protection against strains 16 and 18–those that are responsible for 70% of cervical cancers. More recently, in 2014, the Gardasil 9 vaccine was approved. It protects against a total of 9 HPV strains (6, 11, 16, 18, 31, 33, 45, 52, and 58), covering an even larger percentage of infections.
Part of the answer to this question depends on what your child’s doctor offers and what your insurance company pays for. But if it’s up to you, I’d go for the one that provides the most protection. I mean, none of us wants our kids getting cancer…and we don’t really want them getting genital warts, either. Right?
If the HPV vaccine protects against cervical cancer, why do we give it to boys?
For one, because boys give the virus to girls. Just as our other immunizations provide a degree of protection beyond those who are immunized, the HPV vaccine does as well–even though the virus is transmitted in a different way. If boys never get the virus, they won’t pass it on to future sexual partners. Additionally, while the cervix is the most common site for cancers caused by HPV, boys are at risk for other types of cancer as well.
Is the HPV vaccine a replacement for regular Pap smears?
No–not yet, at least. The HPV vaccine doesn’t protect against every strain that can cause cancer, and it’s not 100% effective. Regular gynecologic exams and Pap smears are still important to catch those cases that slip through. Hopefully, we’ll reach a point some day where the vaccine provides enough protection (and enough people get it), that the need for frequent screening exams will go away. But that won’t be any time soon. Right now, the best plan is to get the vaccine but continue screening starting at age 21.
Is the HPV vaccine required?
Not in most states. At this time, only Virginia, Rhode Island, and the District of Columbia have requirements for entry into 6th or 7th grade. There have been some efforts to mandate the vaccine in other states as well, but for the moment, that’s where we stand. There has been a lot of political debate about parents’ rights vs. public health, safety concerns about the vaccine, and whether we have any business requiring a vaccine to protect against a disease that isn’t spread by typical classroom contact.
I certainly understand parents wanting to make choices about their children’s health and having reasonable concerns about the safety of a new vaccine. But the HPV vaccine is an important public health intervention, and as with any vaccine, it works better when the vast majority of the population is immunized. Currently, only about 40% of teenagers in the US have received the HPV vaccine–a percentage which we hope to improve by increasing awareness about the vaccine and the diseases it prevents.
How well does the HPV vaccine work?
Pretty well…but not as well as it would work if more adolescents got it. Since the vaccine was released in 2006, the number of infections with the covered strains decreased by 56% in adolescent girls (and that’s without all of them getting it…and before the newer vaccine was released). Another study (involving 260,000 girls) showed a decrease of 44% after the vaccine was introduced. When the vaccine was made freely available–but not mandatory–in Australia, infection with cancer-causing HPV types decreased by 61%. A study of women in Denmark showed a 40% reduction in cervical cancers or pre-cancers. And if you have only boys, the vaccine will prevent cancer in them, too.
The science is pretty convincing, but the full effects of the vaccine haven’t yet been seen–partially because we have pathetically low vaccination rates, and partially because it can take decades for women to develop symptoms from an infection they acquire during adolescence or young adulthood.
The HPV vaccine is pretty new–how do we know it’s safe?
One of the biggest problems with the HPV vaccine is the negative press it has received. The HPV vaccine has caused quite a stir–because of a combination of factors. In part, it’s because the vaccine is new. Then there’s the fact that some parents are hesitant about vaccines in general. And then the parents who don’t want to think about the fact that their children will (some day) have sex. And finally, there’s been a lot of irresponsible media reporting about supposed adverse effects.
But when we get down to the science, the reactions we see are things like passing out after an injection (which isn’t all that surprising or dangerous), or local skin infections (which are a risk every time the skin barrier is broken). These reactions aren’t significantly different from what we would see with placebo injections.
And despite claims that the HPV vaccine has been responsible for deaths and severe disabilities, eight years of safety monitoring (about 68 million doses) just hasn’t shown that. Do teenagers die or develop severe diseases in the weeks or months following HPV vaccination? Absolutely. But these things also happen to those who don’t receive the vaccine. I know that sounds grim, but it’s true. And it’s a very important point that seems to be missed by some of the HPV vaccine’s most vocal opponents.
In summary, the HPV vaccine is an important public health measure that has failed to reach its potential because of poor vaccination rates–but even so, has prevented numerous cases of cancer, some of which would have been fatal. And despite tens of millions of doses, there’s just no evidence that the vaccine causes significant harm. The HPV vaccine costs $400 dollars for 3 doses. And it saves lives. Not a bad price to pay.
Due to some recent media attention, I’m reposting my commentary from my Facebook page on 1/28/16:
So the American College of Pediatricians recently released a statement about the HPV vaccine and premature ovarian failure. I’d caution you not to take it too seriously.
#1: the American College of Pediatricians is NOT the American Academy of Pediatrics. It’s a very small (maybe 200 members) group of pediatricians with a political agenda–not the national group that represents pediatricians as a whole. The name is deceiving (and so is their statement).
#2: There is no evidence to say that the HPV vaccine caused the 6 cases of premature ovarian failure that they cite. Should we look into it? Sure. But the majority of reported events after vaccines are totally unrelated to the vaccine–they just occurred around the same time.
#3: HPV kills people. Not just a few. Over 4,000 women per year in the US die of cervical cancer, and that’s not to mention the head and neck cancers that will likely surpass that as the leading cause of HSV-related deaths.
So is infertility from premature ovarian failure bad? Absolutely. But there’s not a good reason to think that these 6 cases were caused by the vaccine–one that has potential to save thousands of lives every year. This is another example of fear-mongering, unfortunately caused by physicians. Be careful what you read and what you believe.